Provider Demographics
NPI:1629707104
Name:BERGER, JASMINE ROSE (LAC)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ROSE
Last Name:BERGER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 E HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2426
Mailing Address - Country:US
Mailing Address - Phone:520-358-8038
Mailing Address - Fax:
Practice Address - Street 1:3050 W AGUA FRIA FWY STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3998
Practice Address - Country:US
Practice Address - Phone:602-802-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20785101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health